Preparation of Medical Supply for Prehospital Emergencies and Disasters: An Internet-Based Simulation Drill

Abstract

Background

Mass casualties caused by natural disasters and man-made events may overwhelm local emergency medical services and healthcare systems. Logistics is essential to a successful emergency medical response. Drills have been used in disaster preparedness to validate plans, policies, procedures, and agreements, and identify resource gaps. The application of the internet to facilitate the conduct of exercise was still limited. This study aimed to investigate the optimal preparation of medical supplies by medical emergency response teams (MERTs) during emergencies and disasters using an internet-based drill.

Methods

An internet-based drill based on real-life mass casualty incidents (MCIs) was developed and conducted in Taiwan from June 2017 to July 2018. The drill involved an MCI with 50 events delivered under two scenarios: (1) reduced transfer capacity and well-functioning local healthcare facilities (emergency module); (2) severely reduced transfer capacity and dysfunctional local healthcare facilities (disaster module). For each event, medical supplies commonly prepared by local MERTs in Taiwan were listed in structured questionnaires and participants selected the supplies they would use.

Results

Forty-three senior medical emergency responders participated in the survey (responding rate of 47.3%). Resuscitation-related supplies increased from emergency to disaster module (e.g., intubation from 9.1% to 13.9%; dopamine from 3.2% to 5.0%; all p < 0.001). In the subgroup analysis of events with life-threatening injuries, the utilization of resuscitation-related supplies (e.g., intubation from 46.6% to 65.3%; p < 0.001) remained higher in the disaster than in the emergency module. Compared to emergency medical technicians, physicians and nurses are more likely to use intravenous/intramuscular analgesics.

Conclusions

The severity of scenarios and the professional background of emergency responders have a different utilization of medical supplies in the simulation drill. The internet-based drill may contribute to optimizing the preparedness of medical response to prehospital emergencies and disasters.

Introduction

Mass casualties caused by natural disasters and man-made events may overwhelm local emergency medical service (EMS) and healthcare systems. 1 - 3 Medical personnel beyond the regular EMS, such as medical emergency response teams (MERTs), had been deployed to provide treatment in the field. 4 , 5 This mechanism might offer a supplementary response to the surge of medical need, especially when the capacity of ambulance transfer or local health facilities is inadequate. Increasing involvement of physicians in certain out-of-hospital scenarios has been reported. 6

Logistics is essential to a successful emergency medical response. The timely provision of medical supplies for MERTs should be well-prepared. 2 , 7 However, the preparation of such medical kits varies in different organizations and areas. The World Health Organization developed the Interagency Emergency Health Kit (IEHK). 8 The content of medical-disaster-response backpacks has been proposed by experts. 7 Individual hospitals may decide the contents of emergency kits, mostly based on their own experiences of medical preparation for mass gatherings. Such emergency kits are neither regularly updated nor validated. Therefore, to investigate the use of medical supplies during emergency events would be valuable for the preparation of the medical supply kits. 9 - 12

A drill is a kind of operations-based exercise often employed to validate a single operation or function. 13 - 15 Drills have been used in disaster preparedness to validate plans, policies, procedures, and agreements, and identify resource gaps. 16 , 17 Participants could reflect their current practices, knowledge, training, and local medical direction in the drills. 18 Traditionally, a drill was often held in a realistic environment and needs several areas for conduct. It is usually costly and could only be delivered at a specific time and space. With the evolution of telecommunication, internet-based simulation has been postulated as an alternative training for disaster management. 19 - 21 However, the application of the internet to facilitate the conduct of exercise was still limited.

An internet-based drill might be considered a new method of exercise. In this study, we intended to develop an internet-based drill using data of real-life emergencies. We then investigated the impact of the transfer capacity and local healthcare resources on the utilization of medical supplies by emergency responders. We also explored the types and amounts of medical supply that are required by different professions of emergency responders in emergencies or disasters.

Methods

Study Design

This study was conducted from June 1, 2017 to July 31, 2018 in a tertiary teaching hospital in Taipei, Taiwan. Using a three-step procedure, an internet-based drill that contained 50 different events was conducted. The results of the drills that constituted two different modules of scenarios were collected and analyzed. Fig. 1 depicts the study protocol.

Fig. 1 . The study protocol.

EMTP: emergency medical technician paramedics.

The first step was to collect and review historical data of medical responses in emergencies and disasters. 22 Data pertaining to all incidents that had occurred between 2011 and 2016 in Taiwan were collected. The data were retrieved from the Emergency Medical Management System of the Ministry of Health and Welfare, Taiwan. Since typhoons are emergencies with longer preparation periods and the response preparation plan, data regarding typhoons were excluded.

Overall, 104 incidents involving more than 15 casualties were reviewed. One hazmat incident and 4 marine incidents were excluded due to the nature of the incidents. A total of 99 incidents, including 2 train incidents, 3 earthquakes, 23 - 28 2 aircraft crashes, 29 , 30 75 road traffic incidents, 31 , 32 15 fire or explosive incidents, 33 - 35 and 2 criminal events, were enrolled as background data to develop the internet-based drill.

The second step was to develop the drill scenarios based on the historical data. To imitate a real, stressful incident, the drill was composed with 50 events. Each event simulated one distinct casualty in a specific condition; that is, each of the simulated casualties had a different type of injury. The injury pattern and severity distribution of patients were provided based on the historical data of real events. Of the 50 events, 8 (16.0%) casualties were triaged as “immediate,” 17 (34.0%) as “delayed,” and 25 (50.0%) as “minor.” For example, 8 casualties had “immediate” life-threatening injuries involving the airway, breathing, circulation, and neurological emergencies.

During emergencies and disasters, the transfer capacity may be reduced because of numerous casualties, limited transfer vehicles, traffic congestion, or road destruction. The local healthcare facilities might be dysfunctional due to the destruction of infrastructures. The transfer capacities and availabilities of local health care systems were common bottlenecks of medical response. Therefore, we designed two different scenarios: Scenario 1 (emergency module [E-module]) and Scenario 2 (disaster module [D-module]). The event conditions and casualties in the two different scenarios were identical except for the transfer capacity and local health care facilities.

Scenario 1 depicted an emergency with mildly reduced transfer capacity during the early hours. Transportation time to the nearest healthcare facility was defined as more than one hour but less than one day. Local healthcare facilities were defined as functioning normally with adequate resources. The E-module simulated a congested situation that some patients needed to be treated in the field but still can be transferred to receiving hospitals during the first few days.

Scenario 2 depicted a disaster with severely reduced transfer capacity. Only a few casualties could be transferred for definite care while most casualties were to be managed in the field for more than one day. Local healthcare facilities were dysfunctional and couldn’t provide emergency care. The transfer of a casualty to definite care facilities occurred over a long distance. The D-module simulated a nearly isolated situation that most patients needed to be treated in the field but were unlikely to be transferred to receiving hospitals during the first few days.

The third step was to enlist the potential items of medical kit. The list of items was based on the medical kits currently used by different local medical response teams in Taiwan. We reviewed four different medical kits and summarized them into a new medical supply list for the internet-based drill.

The drill was then validated by three researchers including two emergency physicians and one senior nurse to formulate as a set of structured questionnaires constructed using Google Forms.

The scenario of the simulated mass casualty incident (MCI) was briefly described in the beginning of the drill. The mission of the participants was to provide emergency medical treatment for each casualty in the field. The participants were asked to choose the procedures, medications, and other medical supplies needed for each event in both two modules. We did not set any time limit; however, a duration of 2 hours was expected to complete the online drill.

The English-translated version of the first event of the internet-based drill is shown in Supplementary Material A.

Study Population

The emergency responders who had medical emergency response experiences were invited to participate in this drill. The list of emergency responders was retrieved from the databank of MERT members, which include physicians, nurses, and emergency medical technician paramedics (EMTPs). Participation in this study was voluntary.

Although nurses and EMTPs were not allowed to perform certain invasive procedures, the participants were permitted to select any procedure or give any medication as necessary in the drill. The participants could add additional supplies that were not listed in the survey form. The records of the medical supplies that were selected for each simulation scenario were then collected and analyzed.

Statistical Analysis

We conducted descriptive analyses and reported the percentages for resuscitation-related supplies, medications, and other medical supplies used by each participant. The unit of analysis was respondent. We compared the data between two modules by the paired t -test.

Timely treatment to the most critical patients is essential in an MCI. We therefore conducted a subgroup analysis of casualties who required immediate treatment using the paired t -test.

We also analyzed the medical supply utilization of each participant according to their profession. The percentages of resuscitation-related supplies, medications, and other medical supplies were compared by analysis of variance tests.

All statistical analyses were performed using SPSS 18.0 Statistics software (SPSS Inc., Chicago, IL, USA).

Results

Participant Demographics

A total of 91 emergency responders were invited to participate; among them, 43 (47.3%) participants responded and participated in this study. The 43 respondents included 14 (32.6%) physicians, 9 (20.9%) nurses, and 20 (46.5%) EMTPs. All the respondents completed the drills of E-module and D-module. The median career period for physicians, nurses, and EMTPs was 7 (interquartile range [IQR] 2–12), 10 (IQR 6–14), and 10 (IQR 7.50–12.55) years, respectively ( Table 1 ).

Table 1 . The characteristics of participants in the internet-based drill (n = 43) .

Characteristics of participants
Age, mean ± SD, years	32.9 ± 4.3
Gender
Male, n (%)	30 (69.8)
Female, n (%)	13 (30.2)
Profession
Physician, n (%)	14 (32.6)
Nurse, n (%)	9 (20.9)
Emergency medical technician-paramedics, n (%)	20 (46.5)
Experience of medical emergency response, mean ± SD, years	8.7 ± 4.0

Comparison of Medical Supplies Used in Both Modules

The descriptive analysis and comparison of results between the two modules are shown in Table 2 . In both modules, the most utilized resuscitation-related supplies, medications, and other medical supplies were similar. The most utilized resuscitation-related supplies per event were intravenous catheters and normal saline infusion. The most prescribed medications were intravenous/intramuscular analgesics and toxoids. The most prescribed other medical supplies per event were gauze and saline irrigation.

Table 2 . Comparative analysis of resuscitation-related supplies, medications, and medical supplies used in two different modules in the internet-based drill .

^* The t -test statistic is significant at the 0.05 level.

Intervention	E-module (n = 43)	D-module (n = 43)	p value
Resuscitation-related supplies (%)
Nasopharyngeal or oropharyngeal airway	4.9	2.7	< 0.001 *
Oxygen mask	18.5	15.3	0.01 *
Intubation	9.1	13.9	< 0.001 *
Sedatives	3.1	5.3	< 0.001 *
Neck collar	9.7	9.0	0.26
Tube thoracostomy	4.7	6.1	0.01 *
Intravenous catheter	34.5	39.2	0.03 *
Normal saline infusion	33.1	38.0	0.02 *
Epinephrine	0.8	0.8	1.00
Dopamine	3.2	5.0	< 0.001 *
Medications (%)
Sodium bicarbonate	2.1	2.4	0.16
IM or IV analgesics	21.1	24.3	0.11
Oral analgesics	14.0	20.8	0.01 *
Intravenous antibiotics	7.6	9.4	0.06
Oral antibiotics	6.4	8.4	0.07
Topical antibiotics ointment	14.8	17.5	0.09
Tranexamic acid	7.0	7.6	0.50
Toxoid	24.1	28.5	0.15
Medical supplies (%)
SAM splint	9.0	8.1	0.17
Cast	5.7	8.5	< 0.001 *
Sling	11.7	9.6	0.04 *
Bandage	23.6	24.5	0.46
Suture kit	10.4	16.8	< 0.001 *
Gauze	44.4	43.5	0.60
Swab	27.3	27.3	0.99
Saline irrigation	41.0	41.4	0.86
Icepack	26.8	29.0	0.27
Tourniquet	5.3	5.1	0.39

All medical supplies used in the two scenarios were then compared. For resuscitation-related supplies, the utilization rates of nasopharyngeal/oropharyngeal airways (4.9% vs. 2.7%, p < 0.001) and oxygen masks (18.5% vs. 15.3%, p = 0.01) decreased from the E-module to D-module. In contrast, aggressive interventions were increasingly performed from E-module to D-module, including intubations (9.1% vs. 13.9%), sedatives (3.1% vs. 5.3%), tube thoracostomies (4.7% vs. 6.1%), intravenous-catheters (34.5% vs. 39.2%), normal saline infusions (33.1% vs. 38.0%), and dopamine administrations (3.2% vs. 5.0%) (All p < 0.05). For medications, the utilization rates also increased from E-module to D-module (oral analgesics 14.0% vs. 20.8%, p = 0.010). Similarly, additional casts (8.5% vs. 5.7%, p < 0.001) and suture kits (16.8% vs. 10.4%, p < 0.001) were used in D-module.

Comparison of Medical Supplies Used for the Patients Requiring Immediate Treatment

Since the casualties triaged as “immediate” were the most affected group when transfer capacity was compromised, a subgroup analysis of all medical supplies used in each event in the two different modules was performed ( Table 3 ). Among the resuscitation-related supplies, utilization rates of nasopharyngeal or oropharyngeal airways (21.6% vs. 9.0%, p < 0.001), and oxygen masks (46.6% vs. 28.3%, p < 0.001) decreased from E-module to D-module. The decision of intubations (46.6% vs. 65.3%, p < 0.001) was still increasingly performed from E-module to D-module. The utilization of medications was not significantly different between the two modules.

Table 3 . Subgroup analysis of resuscitation-related supplies, medications, and medical supplies used in events with life-threatening injuries in two different modules .

^* The t -test statistic is significant at the 0.05 level.

Intervention	E-module (n = 43)	D-module (n = 43)	p value
Resuscitation-related supplies (%)
Nasopharyngeal or oropharyngeal airway	21.6	9.0	< 0.001 *
Oxygen mask	46.6	28.3	< 0.001 *
Intubation	46.6	65.3	< 0.001 *
Sedatives	14.2	18.2	0.10
Neck collar	31.6	31.1	0.81
Tube thoracostomy	19.7	21.4	0.37
Intravenous catheter	77.3	74.6	0.57
Normal saline infusion	73.9	72.8	0.81
Epinephrine	4.1	4.1	1.00
Dopamine	20.8	24.0	0.19
Medications (%)
Sodium bicarbonate	3.7	3.8	0.92
IM or IV analgesics	1.3	2.1	0.17
Oral analgesics	14.8	16.0	0.48
Intravenous antibiotics	1.3	1.6	0.57
Oral antibiotics	10.1	10.5	0.78
Topical antibiotics ointment	16.5	16.8	0.82
Tranexamic acid	18.5	19.4	0.70
Toxoid	9.6	6.8	0.07
Medical supplies (%)
SAM splint	0.5	0.5	1.00
Cast	0.5	0.5	1.00
Sling	8.6	7.8	0.54
Bandage	15.3	16.7	0.47
Suture kit	33.3	30.3	0.14
Gauze	9.4	6.8	0.03 *
Swab	30.5	28.0	0.23
Saline irrigation	16.1	13.4	0.23
Icepack	0.9	0.9	1.00
Tourniquet	16.0	23.5	0.01 *

Comparison of Medical Supplies Used by Emergency Responders of Different Professions

In the E-module, the utilization rates of resuscitation-related resources were not significantly different between emergency responders of different professions ( Table 4 ). Physicians and nurses, compared to EMTPs, utilized more intravenous/intramuscular analgesics (31.7% vs. 29.0% vs. 10.2%, p = 0.001).

Table 4 . Comparative analysis of resuscitation-related supplies, medications, and medical supplies used by emergency responders of different professions in E-module in the internet-based simulation .

^* The analysis of variances (ANOVA) statistic is significant at the 0.05 level.

Intervention	Physician (n = 14)	Nurse (n = 9)	EMTP (n = 20)	p value
Resuscitation procedures (%)
Nasopharyngeal or oropharyngeal airway	5.4	3.1	5.4	0.55
Oxygen mask	13.9	18.1	21.8	0.08
Intubation	7.0	13.0	8.7	0.11
Sedatives	2.6	3.0	3.4	0.91
Neck collar	9.3	7.9	10.9	0.57
Tube thoracostomy	4.7	4.6	4.7	0.99
Intravenous catheter	31.9	35.7	35.7	0.81
Normal saline infusion	33.1	34.0	32.7	0.98
Epinephrine	0.4	1.6	0.8	0.56
Dopamine	2.4	3.9	3.4	0.74
Medications (%)
Sodium bicarbonate	1.8	0.0	3.3	0.16
IM or IV analgesics	31.7	29.0	10.2	0.001 *
Oral analgesics	21.0	11.4	10.2	0.16
IV antibiotics	13.0	9.0	3.3	0.06
Oral antibiotics	11.4	6.4	3.0	0.13
Topical antibiotics ointment	20.3	20.8	8.2	0.07
Tranexamic acid	11.8	8.0	3.3	0.13
Toxoid	30.5	34.0	15.3	0.08
Medical supplies (%)
SAM splint	5.2	12.1	10.3	0.05
Cast	7.4	4.4	5.1	0.57
Suture kit	13.0	13.8	7.0	0.08
Sling	7.9	5.9	16.9	0.003 *
Bandage	25.2	23.0	22.7	0.84
Gauze	39.9	46.1	46.8	0.34
Swab	38.5	41.1	13.2	< 0.001 *
Saline irrigation	42.6	44.7	38.3	0.63
Icepack	35.5	32.4	18.2	0.03 *
Tourniquet	4.6	3.6	6.5	0.49

In the D-module, among resuscitation-related resources, the utilization rate of tube thoracostomy was significantly different between emergency responders of different professions (physicians vs. nurses vs. EMTPs: 4.4% vs. 5.9% vs. 7.4%, p = 0.001) ( Table 5 ). Physicians, compared to nurses or EMTPs, utilized more intravenous/intramuscular analgesics (35.0% vs. 27.5% vs. 15.4%), oral analgesics (34.6% vs. 11.4% vs. 15.3%), intravenous antibiotics (15.2% vs. 9.4% vs. 5.4%) and oral antibiotics (17.0% vs. 5.8% vs. 3.5%) (All p < 0.05). Significant differences were found among physicians, nurses, and EMTPs regarding the use of structural aluminum malleable splint (3.0% vs. 10.7% vs. 10.5%, p = 0.002) and swab (38.2% vs. 39.1% vs. 14.3%, p < 0.001).

Table 5 . Comparative analysis of resuscitation-related supplies, medications, and medical supplies used by the emergency responders of different professions in disaster module in the internet-based drill .

^* The analysis of variances (ANOVA) statistic is significant at the 0.05 level.

Intervention	Physician (n = 14)	Nurse (n = 9)	EMTP (n = 20)	p value
Resuscitation procedures
Nasopharyngeal or oropharyngeal airway	2.1	1.3	3.7	0.53
Oxygen mask	9.0	13.9	20.3	0.02 *
Intubation	12.5	19.0	12.7	0.15
Sedatives	4.3	4.1	6.5	0.58
Neck collar	8.4	6.4	10.7	0.24
Tube thoracostomy	4.4	5.9	7.4	0.001 *
IV catheter	34.6	37.3	43.2	0.27
Normal saline infusion	36.5	35.6	40.1	0.71
Epinephrine	0.4	1.3	0.9	0.69
Dopamine	4.3	4.1	6.5	0.45
Medications
Sodium bicarbonate	3.0	10.7	10.5	0.26
IM or IV analgesics	35.0	27.5	15.4	0.003 *
Oral analgesics	34.6	11.4	15.3	0.001 *
IV antibiotics	15.2	9.4	5.4	0.02 *
Oral antibiotics	17.0	5.8	3.5	0.01 *
Topical antibiotics ointment	22.7	23.5	11.1	0.09
Tranexamic acid	11.5	7.8	4.8	0.24
Toxoid	38.0	30.5	21.0	0.06
Medical supplies
SAM splint	3.0	10.7	10.5	0.002 *
Cast	10.0	7.2	8.0	0.62
Suture kit	6.6	5.9	13.4	0.49
Sling	6.6	5.9	13.4	0.04 *
Bandage	26.5	21.9	24.2	0.71
Gauze	40.2	44.8	45.2	0.48
Swab	38.2	39.1	14.3	< 0.001 *
Saline irrigation	44.6	43.1	38.4	0.54
Icepack	33.3	32.1	24.7	0.37
Tourniquet	4.7	3.4	6.0	0.61

Discussion

We developed a feasible, internet-based drill, and our study results could provide important information for future disaster preparation. We found that the need of resuscitation-related supplies drastically increased when the capacity of ambulance transfer and local healthcare facilities was severely reduced. The need of intubation-related supplies was even higher for critically injured casualties. The analgesics were more commonly utilized by physicians and nurses than EMTPs. Thus, the medical supply kits might be prepared according to the circumstances of incidents and the profession of the emergency responders.

Appropriately prepared reserves of medical supplies are crucial to the success of a prehospital medical response to an emergency or disaster. 18 However, there were very few references regarding possible compositions in the pre-assembled medical supply kits. Disaster responders reported an abrupt transition from their usual working contents that required adaptation to practice properly and effectively. 36 The World Health Organization had developed the IEHK to meet the first primary healthcare needs of a displaced population without medical facilities. 8 However, the IEHK does not contain necessary equipment for resuscitation or major surgery. The IEHK may be insufficient for the initial response to MCIs, such as earthquakes or devastating traffic accidents.

Schultz et al. 7 advised specific items to be included in the backpack for first medical responders. According to our results, at least two different sets of medical supplies might be developed to meet the needs. In disastrous events such as earthquakes or when the traffic and healthcare facilities are severely disrupted, the first responders would be more aggressive and perform more invasive procedures. The first responders tend to request more medical supplies for resuscitation procedures and to prescribe more analgesics. The responders may consider the transfer capacity and the availability of healthcare facilities in different scenarios; therefore, they might change their decision on what procedures might best benefit the patients. The results of our study also showed that this factor did alter the evaluation of the needs in the field. In the more resource-critical environment, the responders might consider a more definite treatment in order to adequately stabilize the patient at the scene.

The profession of responders also plays a role in the evaluation of the needs. Compared with EMTPs, the physicians and nurses might be more comfortable having medications involved in their management plans. The disparity of management plans among different professions reflects their current practices, knowledge, training, and local medical direction. We did not analyze the effect of prior participation in disaster medical assistant teams due to the limited number of participants. Although the participants’ experiences could be considerably diverse, the personal characters and the intensity of involvement in disaster response could be an important issue for disaster planning.

Considering the limitation of the weight and size of the medical kits, the items prepared in such kits should meet the most critical needs in the field. For medical supplies with low utilization rate, they should be considered to be eliminated or prepared in small amount to save the transport capacity. The ideal content of a medical kit is beyond the scope of this study. The lists of equipment and medication in the kit could be adjusted according to the professionals of disaster response team, the objectives of mission, the condition of disasters, and the resources of allied organizations. To minimize the complexity in real practice, a uniformed “essential kit” along with several types of “optional kits” could be considered.

Creative drills can test protocols and identify key gaps to improve the capability in responding to various types of incidents. 37 The methodology used to develop and validate the contents of medical supply kits for medical emergency response is seldom discussed in the literature. The current medical kit supplies for MERTs are largely based on the expert’s opinion and data from a few disaster experiences. 8 - 11 Sadewasser et al. 11 performed a literature review to investigate the prehospital and retrieval drug requirements. Our study used a newly designed method, which was modified from the traditional drills, to investigate the preparation of medical supply utilization.

Our method has several advantages, This simulated drill was using historical data of real-life incidents, which can reflect the real disaster epidemiology. The two types of scenarios in this study were based on the past emergencies and disasters that occurred in Taiwan, which were also the most common challenges in disaster preparation. Further investigations of other conditions should be conducted according to the local emergency response plans. Our newly developed drills provide a feasible example for future surveys.

Furthermore, we used a simulation drill as the basic structure for evaluation. Drills are one type of operations-based exercises, which are used to validate plans, policies, procedures, and agreements; and identify resource gaps. Drills have been used in disaster preparedness and training for decades. 13 - 15 The participants’ responses in the drill reflected their usual practice in the field based on their current knowledge, training, and local medical direction. 16 , 17 , 19 , 20 Thus, the results of the drill can provide a more feasible and practical viewpoint. Our study results provided a recommendation for the revision of current medical kits, which could be adapted by local authorities.

Unlike the traditional drill, our drill was conducted and delivered through the internet. Internet-based drills are highly cost-effective and have minimal time and space limitations. This method could be an alternative way to conduct a drill, especially during the pandemics when face-to-face meetings are likely infeasible.

This study has several limitations. First, since the simulation was based on our real emergencies in Taiwan, the results might not be generalized to other regions. However, the simulation in this study included injuries conventionally found in guidelines for essential trauma care services. 12 , 32 Thus, our study results could represent the situation commonly encountered in emergencies and reflect the medical supply needs. Second, the response rate of our survey should be improved. The respondents could be unfamiliar with this novel, internet-based drill. We suggest that the computer-human interface and the drill scenarios should be simplified to improve the participation rate. We also found that the questionnaires should be shortened since the participants had to review 50 cases repeated in two different scenarios, which was time-consuming. Third, some of the medical supplies were not listed in our precedent lists of medical supply kits. Thus, some supplies which might be critical, such as portable ventilators, oxygen tanks needed after intubation, or pelvic binders, could not be evaluated by our study. However, since medical supplies were complicated and various, it was unlikely to include all items in the drill. Although this research provides evidence to determine the optimal medical supply preparation for prehospital emergencies and disasters, the quantity issue was not considered. Furthermore, during the response of real-world events, health providers can follow up on the patient’s condition, monitor the result of medical intervention, and modify the management accordingly. In this drill, we did not provide any feedback on the clinical condition when the drill participants had chosen the medical equipment or medication for the simulated patients. Since the purpose of this study was to evaluate the preparation of medical supply, the result of our drill is suitable rather for logistic needs in the initial phase of response. Finally, we did not include psychological issues or occupational health considerations in this study, which may affect the need of medical supply in responding to emergencies or disasters. 38 - 40

In conclusion, our study used an internet-based drill to determine the optimal preparation of medical supply for prehospital emergencies and disasters. The emergency managers should consider the capacity of transfer local healthcare facilities in preparing medical supply kits for MERTs. This study revealed that the utilization of resuscitation-related medical supplies increased significantly in the disaster module. The utilization of analgesics was different among different professions of responders. The internet-based drill may be utilized as an alternative method for optimizing preparedness of medical response to prehospital emergencies and disasters.

Conflicts of Interest Statement

The authors report none of conflict of interests.

Acknowledgments

None.

Supplementary material A: The English-translated version of the web-based simulation.

The simulation scenario

A mass casualty incident has occurred in the area (possibly a land-based traffic accident, an air crash, an earthquake, a collapsed building, etc.), and you are deployed by the Ministry of Health and Welfare, Taiwan (R.O.C.) to the scene to provide emergency medical care. The accident is not a hazardous materials incident (such as chemical hazards, biological hazards, or radiological hazards). The time of medical assistance is expected to be 6-24 hours after the incident.

Scenario 1

When you arrived at the scene, you found that there are many casualties needing medical care. At present, the transfer capacity has reduced due to a large number of casualties, limited transfer vehicles, and traffic congestion during the early hours. The transportation time to the nearest hospital was defined to be more than one hour but less than a day. The hospitals in the area were functioning normally but all had received large numbers of injuries.

Based on your experience and training, first, please assess the casualties according to the information provided and assign a triage category according to START (Simple Triage and Rapid Treatment). Then, consider that you are in a prehospital setting, please provide medical treatment to the casualties. Currently, there was enough medical staff on site, so you have time to perform any necessary medical treatment. However, please limit your response to the treatments that can be performed outside the hospital.

If you are an EMT-P or a nurse, you can respond according to your professional knowledge without considering any legal issues or your capability in performing the technique (e.g. plastering, suturing, etc.). In other words, if you judge that a medical treatment should be performed in the field based on your experience, then you can just check the box. The followings are all multiple-choice questions. Please check all the procedures, and/or equipment/ materials used in medical treatments that you think are necessary for each casualty.

Patient 1 32-year-old female

The patient is able to walk.

She has multiple abrasions on both knees (left: 4X3 cm, right: 6X4 cm) and left palm (3X3 cm). Another 4-cm laceration on her left lower leg is bleeding actively.

Q1. According to the START triage system, which of the following triage category will you assign to this patient?

□ Deceased (Black)

□ Immediate (Red)

□ Delayed (Yellow)

□ Minor (Green)

Q2. What emergency medical treatment would you perform on this patient? (Primary survey is considered in this section. You do not need to select anything if you think none of the items are needed. Leaving all boxes blank means [none of the items are needed.]) (Multiple selections accepted)

□ Nasopharyngeal or oropharyngeal airway

□ Oxygen mask

□ Intubation

□ Neck collar

□ Tube thoracostomy

□ Set ONE intravenous catheter

□ Set TWO intravenous catheters

□ Infusion ONE bag (500ml/bag) of normal saline/lactated Ringer’s solution; total 500ml

□ Infusion TWO bags (500ml/bag) of normal saline/lactated Ringer’s solution; total 1000ml

□ Infusion FOUR bags (500ml/bag) of normal saline/lactated Ringer’s solution; total 2000ml

□ Adrenaline (epinephrine 1 mg/1 mL)

□ Anxicam (lorazepam 2mg /1 ml/amp)

□ Dormicum (midazolam 5 mg/1 mL /amp)

□ Others:

Q3. Besides the above-mentioned resuscitation procedures, what kind of additional medical treatment will you perform? (Please specify the number of possible uses; if you do not need it, choose 0.)

Please provide only one number for each item.

□ SAM splint

□ Plaster cast (3 inch)

□ Plaster cast (6 inch)

□ Sling

□ Bandage

□ Suture set (with 2-0 Nylon stitches)

□ Suture set (with 4-0 Nylon stitches)

□ Gauze (2 pieces per pack)

□ Sterile burn sheet (1 piece per pack)

□ Small cotton swabs (6 sticks/pack)

□ Large cotton swabs (6 sticks/pack)

□ Normal saline for irrigation (500ml/bottle)

□ Icepack

□ Tourniquet

Q4. What medication will you give the patient? (You do not need to select any item if you think none of the items are necessary)

● Life support medicine

□ Rolikan (sodium bicarbonate 16.6 mEq/20 mL/amp)

□ Easydopa (dopamine 400 mg/250 mL/bag)

□ Others:

● Analgesics

□ Injection form: Morphine (morphine 10 mg/1 mL /amp)

□ Injection form: Tramal (tramadol HCl 100 mg/2 mL/amp)

□ Injection form: Bain (nalbuphine HCl 10 mg/1 mL/amp)

□ Oral form: Paramol (acetaminophen 500 mg/tab)

□ Oral form: nonsteroidal anti-inflammatory drugs (NSAIDs)

□ Others:

● Antibiotics

□ Injection form: Cefa (1000 mg Cefazolin/vial)

□ Injection form: Augmentin (500 mg amoxicillin & 100 mg clavulanic acid/vial)

□ Oral form: Cephalexin Capsule 250 mg/cap

□ Oral form: Augmentin 1 g F.C. Tablet (875 mg amoxicillin & 125 mg clavulanic acid/tab)

□ Antibiotic ointment

□ Others:

● Other medicine:

□ Injection form: Transamin (Tranexamic acid 5% 250 mg/5 mL/amp)

□ Injection form: Tetanus Toxoid (0.5 mL/dose)

□ Others:

Q5: Are there any other equipment, medicines, or materials you need to use? If yes, please write your answer in the blank below:

Scenario 2

Imagine that you are sent to an area with severely reduced transfer capacity where only a few casualties could be transferred to definite care and most casualties were to be managed in the field for more than one day. The local healthcare facilities were disabled and the transfer of a casualty to definite care facilities occurred over a long distance. (i.e., the patient may need to be transported by helicopter if necessary). The transport time is estimated to range from several hours to more than one day. You are assigned to work in the field for 72 hours.

Q: Will you change your management in this scenario, compared with those in scenario 1?

□ Yes (Please fill in the following questions)

□ No (Please skip to the next patient)

Patient 1 32-year-old female

The patient is able to walk.

She has multiple abrasions on both knees (left: 4X3 cm, right: 6X4 cm) and left palm (3X3 cm). Another 4-cm laceration on her left lower leg is bleeding actively.

Q1. According to the START triage system, which of the following triage category will you assign to this patient?

□ Deceased (Black)

□ Immediate (Red)

□ Delayed (Yellow)

□ Minor (Green)

Q2. What emergency medical treatment would you perform on this patient? (Primary survey is considered in this section. You do not need to select anything if you think none of the items are needed. Leaving all boxes blank means [none of the items are needed.]) (Multiple selections accepted)

□ Nasopharyngeal or oropharyngeal airway

□ Oxygen mask

□ Intubation

□ Neck collar

□ Tube thoracostomy

□ Set ONE intravenous catheter

□ Set TWO intravenous catheters

□ Infusion ONE bag (500ml/bag) of normal saline/lactated Ringer’s solution; total 500ml

□ Infusion TWO bags (500ml/bag) of normal saline/lactated Ringer’s solution; total 1000ml

□ Infusion FOUR bags (500ml/bag) of normal saline/lactated Ringer’s solution; total 2000ml

□ Adrenaline (epinephrine 1 mg/1 mL)

□ Anxicam (lorazepam 2mg /1 ml/amp)

□ Dormicum (midazolam 5 mg/1 mL /amp)

□ Others:

Q3. Besides the above-mentioned resuscitation procedures, what kind of additional medical treatment will you perform? (Please specify the number of possible use, if you do not need it, choose 0)

Please provide only one number for each item.

□ SAM splint

□ Plaster cast (3 inch)

□ Plaster cast (6 inch)

□ Sling

□ Bandage

□ Suture set (with 2-0 Nylon stitches)

□ Suture set (with 4-0 Nylon stitches)

□ Gauze (2 pieces per pack)

□ Sterile burn sheet (1 piece per pack)

□ Small cotton swabs (6 sticks/pack)

□ Large cotton swabs (6 sticks/pack)

□ Normal saline for irrigation (500ml/bottle)

□ Icepack

□ Tourniquet

Q4. What medication will you give the patient? (You do not need to select any item if you think none of the items are necessary)

● Life support medicine

□ Rolikan (sodium bicarbonate 16.6 mEq/20 mL/amp)

□ Easydopa (dopamine 400 mg/250 mL/bag)

□ Others:

● Analgesics

□ Injection form: Morphine (morphine 10 mg/1 mL /amp)

□ Injection form: Tramal (tramadol HCl 100 mg/2 mL/amp)

□ Injection form: Bain (nalbuphine HCl 10 mg/1 mL/amp)

□ Oral form: Paramol (acetaminophen 500 mg/tab)

□ Oral form: nonsteroidal anti-inflammatory drugs (NSAIDs)

□ Others:

● Antibiotics

□ Injection form: Cefa (1000 mg Cefazolin/vial)

□ Injection form: Augmentin (500 mg amoxicillin & 100 mg clavulanic acid/vial)

□ Oral form: Cephalexin Capsule 250 mg/cap

□ Oral form: Augmentin 1 g F.C. Tablet (875 mg amoxicillin & 125 mg clavulanic acid/tab)

□ Antibiotic ointment

□ Others:

● Other medicine:

□ Injection form: Transamin (Tranexamic acid 5% 250 mg/5 mL/amp)

□ Injection form: Tetanus Toxoid (0.5 mL/dose)

□ Others:

Q5: Are there any other equipment, medicines, or materials you need to use? If yes, please write your answer in the blank below: